Efficacy and safety of drug-coated balloon for de novo lesions of large coronary arteries: Systematic review and meta-analysis of randomized controlled trials.

Background: Drug-coated balloon (DCB) is a novel approach to avoiding stent-related complications and has proven effective for the treatment of in-stent restenosis (ISR) and small vessels. However, its role in the treatment of de novo lesions in large vessels is less settled. Aims: To estimate the efficacy and safety of drug-coated balloon versus stent in the treatment of de novo lesions in large coronary arteries. Methods: We searched the literature until April 2023. We judged the safety of DCB based on major adverse cardiovascular events (MACEs), cardiac death, all-cause mortality, non-fatal myocardial infarction, target lesion revascularization (TLR), and bleeding event; and efficacy according to late lumen loss (LLL), minimum lumen diameter (MLD). We conducted subgroup analyses according to stent type and whether urgent PCI was required. Results: A total of 10 RCTs were included. Overall, LLL (mean difference (MD) = -0.19, 95 % confidence interval (CI): -0.32 to -0.06, P = 0.003) was lower in the DCB group than in the Stent arm. This effect was consistent in subgroup analysis regardless of stent type and disease type. In terms of safety indicators, there were no significant differences between DCB and stent. The subgroup analyses found that safety indicators showed no significant differences between DCB and drug-eluting stent (DES), but TLR was lower in the DCB than in the bare metal stent (BMS). Moreover, in ST-elevation myocardial infarction (STEMI), safety indicators and LLL showed no significant differences between DCB and DES, but MLD in the DCB was smaller. While in patients with excluded STEMI, MACE and TLR was lower in the DCB compared with the overall stent. Conclusions: DCB could be a promising alternative for treating de novo lesions in large coronary arteries with satisfactory efficacy and low risk, superior to BMS and not inferior to DES, with a trend toward lower late lumen loss.

Correlation between the Position of the Pituitary Stalk as Determined by Diffusion Tensor Imaging and Its Location as Determined at the Time of Surgical Resection of Pituitary Adenomas.

OBJECTIVE: An important factor during pituitary adenoma surgery is to preserve pituitary stalk (PS) as this plays a role in reduction of the risk of postoperative diabetes insipidus. The hypothalamic-hypophyseal tract (HHT) projects through the PS to the posterior pituitary gland. To reconstruct white matter fiber pathways, methods like diffusion tensor imaging (DTI) tractography have been widely used. In this report we attempted to predict the position of PS using DTI tractography and to assess its intraoperative correlation during surgery of pituitary adenomas. METHODS: DTI tractography was used to tract the HHT in nine patients before craniotomy for pituitary adenomas. The DTI location of the HHT was compared with the PS position identified at the time of surgery. DTI fiber tracking was carried out in nine patients prior to the planned craniotomy for pituitary adenomas. In one patient, the PS could not be identified during the surgery. In the other eight patients, a comparison was made between the location of the HHT identified by DTI and the position of the PS visualized at the time of surgery. RESULTS: The position of the HHT identified by DTI showed consistency with the intraoperative position of the PS in seven patients (88.9% concordance). CONCLUSION: This study shows that DTI can identify the position of the HHT and thus the position of the PS with a high degree of reliability.

Microsurgical treatment of craniopharyngioma: Experiences on 183 consecutive patients.

This study aimed to summarize the clinical experiences and postoperative effects of microsurgical approaches for craniopharyngioma.A total of 183 craniopharyngioma patients who underwent microsurgical treatment since March 2009 to March 2015 in our hospital were included in current research. Surgical approaches were selected based on preoperative evaluations, including tumor locations, sizes, and growth patterns. Active measurements to manage water-electrolyte disorder and insipidus were taken for postoperative treatments. During the follow-up, patients were monitored for residual or recurrent tumor by postoperative contrast MRI scans done 1 to 3 months after surgery.The used surgical approaches were as follows: frontopterional approach (76 cases), anterior interhemispheric approach (58 cases), transcallosal approach (10 cases), transsphenoidal approach (15 cases), unilateral subfrontal approach (15 cases), and combined approaches (9 cases). Around 124 cases (72.7%) received total tumor resection, 37 patients (20.2%) underwent subtotal resection, and 13 patients (7.1%) underwent partial removal. No significant difference was found on the postoperative complications among the different microsurgical approaches (all, P > .05). A total of 111 cases had an intact pituitary stalk preservation and 26 cases had partially preserved stalks during surgery. Visual improvement was achieved in 54 patients and visual deterioration occurred in 22 cases. Postoperative insipidus appeared in 114 cases and water-electrolyte disorder occurred in 99 cases. The postsurgical follow-up ranged from 3 to 69 months with a mean duration of 27.3 months and 23 patients suffered recurrence.Based on careful preoperative evaluation, microsurgical treatments may be safe and effective approach to improve postoperative outcomes of craniopharyngioma patients.

Anterior interhemispheric approach for removing large sellar region tumor.

The aim of the study was to explore anterior interhemispheric approach microsurgery for removing large sellar region tumors.A total of 118 patients with large sellar region tumors were treated with the anterior interhemispheric approach microsurgery. There were 58 craniopharyngioma, 37 pituitary adenoma, 5 hypothalamic glioma, 7 meningioma, and 11 other tumors cases. The maximal tumor diameter ranged from 3.0 to 8.2 cm, with a mean diameter of 4.3 cm. Diabetes insipidus and fluid and electrolyte imbalance were timely controlled after surgery. Postoperative examination of endocrine and of magnetic resonance imaging (MRI) enhancement scanning of the head were performed.Total, subtotal, and partial removal of tumors was, respectively, achieved in 80, 23, and 15 cases. A total of 109 patients had improved vision after surgery. During the hospital stay, 81 had diabetes insipidus, 68 had fluid and electrolyte imbalance, and 9 had hemorrhage and tumidness in the right frontal lobe (3 had frontal lobe contusion, and 6 had frontal lobe hematoma). The postoperative follow-up visit lasted for 3 to 105 months. During the follow-up period, 14 patients had recurrence of tumors, 38 cases had their single or multiple pituitary axis treated with hormonal replacement therapy for a long time after surgery, and 23 cases had to orally take drugs for the purpose of controlling diabetes insipidus.The anterior interhemispheric approach microsurgery is feasible for removing large sellar region tumors without significant sequels. Active postoperative managements of diabetes insipidus and fluid and electrolyte imbalance may help patients with earlier recovery.

[Functional neuro-navigation and intraoperative magnetic resonance imaging for the resection of gliomas involving eloquent language structures].

OBJECTIVES: To explore the clinical value of functional neuro-navigation and high-field-strength intraoperative magnetic resonance imaging (iMRI) for the resection of intracerebral gliomas involving eloquent language structures. METHODS: From April 2009 to April 2010, 48 patients with intracerebral gliomas involving eloquent language structures, were operated with functional neuro-navigation and iMRI. Blood oxygen level dependent functional MRI (BOLD-fMRI) was used to depict both Broca and Wernicke cortex, while diffusion tensor imaging (DTI) based fiber tracking was used to delineate arcuate fasciculus. The reconstructed language structures were integrated into a navigation system, so that intra-operative microscopic-based functional neuro-navigation could be achieved. iMRI was used to update the images for both language structures and residual tumors. All patients were evaluated for language function pre-operatively and post-operatively upon short-term and long-term follow-up. RESULTS: In all patients, functional neuro-navigation and iMRI were successfully achieved. In 38 cases (79.2%), gross total resection was accomplished, while in the rest 10 cases (20.8%), subtotal resection was achieved. Only 1 case (2.1%) developed long-term (more than 3 months) new language function deficits at post-operative follow-up. No peri-operative mortality was recorded. CONCLUSIONS: With functional neuro-navigation and iMRI, the eloquent structures for language can be precisely located, while the resection size can be accurately evaluated intra-operatively. This technique is safe and helpful for preservation of language function.

Revascularization for complex cerebral aneurysms.

BACKGROUND AND PURPOSE: Complex cerebral aneurysms may require indirect treatment with revascularization. This manuscript describes various surgical revascularization techniques together with clinical outcomes. METHODS: Thirty-two consecutive patients with complex cerebral aneurysm were managed from November 2005 to October 2008. Techniques used for revascularization were high-flow bypass, low-flow bypass, branch artery reimplantion, and primary reanastomosis. Physiologic and anatomic monitoring technologies, including electroencephalography, somatosensory evoked potential monitoring, microvascular doppler ultrasonography, and/or indocyanine green videoangiography were used intraoperatively to assess both brain physiology and vascular anatomy. Patient outcome was determined using the Glasgow Outcome Scale at discharge and at a mean of 12 months post operation (range 6-25 months). RESULTS: Two cervical carotid aneurysms (6%) were resected followed by primary reanastomosis, 21 aneurysms (66%) were trapped following saphenous vein high-flow bypasses, five (16%) were clipped after superficial temporal or occipital artery low-flow bypasses, and four (12%) middle cerebral branch arteries were reimplanted. Of the 32 patients at discharge, 29 (91%) had a Glasgow Outcome Scale of four or five, two (6%) had severe disability, and one (3%) died. CONCLUSION: Cerebral revascularization remains an effective and reliable procedure for treatment of complex cerebral aneurysms. Low morbidity and mortality rates reflect the maturity of patient selection and surgical technique in the management of these lesions.

[Extracranial-intracranial revascularization techniques in the treatment of complex aneurysms and prevention and management of occlusion of bypass vessels].

OBJECTIVES: To study the revascularization techniques in the treatment of intracranial complex aneurysms and occlusive reasons of bypass vessel. METHODS: The 20 complex intracranial aneurysms who underwent saphenous bypass treatment from November 2006 to November 2008 were retrospectively analyzed and the occlusive reasons were studied. Of the 20 patients, 12 were female and 8 were male, mean age was 54.5 years (ranged 27 - 65 years). The distribution of the lesions included 13 cavernous sinus aneurysms, 4 para-clinoid aneurysms, 2 supraclinoid aneurysms, and 1 basilar trunk aneurysm. Four aneurysms were giant (diameter > 25 mm), 12 aneurysms were large (15 - 25 mm), and 4 aneurysms were medium (10 - 15 mm) size. RESULTS: One saphenous vein was occluded intraoperatively and one saphenous vein was occluded postoperatively. At discharge, 18 out of the 20 patients had Glasgow Outcome Scale (GOS) score of 4 or 5, 2 patients had score of 3, and 1 patient had score of 1. At 6 months follow up, 18 of 19 survivors had GOS score of 4 or 5 and 1 patient had score of 3. CONCLUSIONS: Extracranial-intracranial revascularization technique is a safe and effective method in the treatment of complex aneurysms. Mechanical and hemodynamic factors are two leading reasons for occlusion of bypass vessels. Long-term bypass vessels patent rate still needs further observation.

[The analysis of intracranial aneurysms undergoing surgical treatment].

OBJECTIVE: To study the surgical principles and treatment options of intracranial aneurysms. METHODS: One hundred and thirty nine patients with intracranial aneurysms were retrospectively studied, including 80 open-surgery cases and 59 endovascular-treated cases from January to December in 2009. Open surgical methods included clipping, trapping or wrapping and interventional methods included simple coiling or stent-assisted coiling. Intra-operative electroencephalogram and somatosensory evoked potentials monitoring were regularly used. Microvascular doppler ultrasonography and indocyanine green videoangiography were used to assess blood flow in parent and branch vessels. RESULTS: Seventy-three aneurysms were directly clipped, 6 were trapped and 1 was wrapped. Thirty-three aneurysms were coiled and 26 were coiled assisted with stents. At discharge, 71 of the 80(88.8%) surgical treated patients had Glasgow Outcome Scale score of 4 or 5 points, 3 points in 6 patients (7.5%), 2 points in 1 patient (1.2%), and 1 point in 2 patients (2.5%). Fifty-four out of 59 cases underwent endovascular treatment scored 4 or 5 points (91.5%) and 3 points in 5 patients (8.5%). CONCLUSIONS: Surgical clipping and endovascular coiling are two major treatment choices for intracranial aneurysms. The treatment option should be individualized based on the patients' specific conditions, which could have a safe, effective and durable outcome.

Microsurgical management of large and giant paraclinoid aneurysms.

BACKGROUND: Because of the complex topographic anatomical relationship between vascular, dural and bone structures, paraclinoid aneurysms, especially those of larger size, remain a great challenge for vascular neurosurgeons. We present our microneurosurgical experience of 51 consecutive patients with large and giant paraclinoid aneurysms to scrutinize our personal strategies related to surgical treatment. METHODS: Fifty-one patients with large or giant paraclinoid underwent micorneurosurgical aneurysm treatment. Operative strategies were planned according to preoperative state-of-the-art imaging studies, and a pterional-transsylvian approach was routinely used. Proximal control of the internal carotid artery (ICA) was achieved by exposure of the cervical portion of the vessel. Intraoperative electroencephalogram and somatosensory evoked potential monitoring, indocyanine green (ICG) videoangiography and/or microvascular Doppler ultrasonography (MDU) were regularly used. A postoperative digital subtraction angiography or computed tomography angiography was performed to verify the efficacy of treatment. RESULTS: Forty-three large and giant paraclinoid aneurysm necks (84%) were directly clipped, seven unclippable aneurysms (14%) were trapped with extra-intracranial high-flow revascularization, and one aneurysm (2%) was treated with only ICA proximal Hunterian ligation. Two patients (4%) died in the early postoperative period. In 84% of the patients, the Glasgow Outcome Scale score was 4 or 5 at discharge. At the 6-month follow-up examination, the Rankin Outcome Scale score was 0-2 in 90% of patients. CONCLUSIONS: Temporary parent vessel occlusion, retrograde suction decompression, endoaneurysmectomy, parent vessel clip reconstruction, and bypass vascular anastomosis are essential techniques to treat complex paraclinoid aneurysms. The combined use of electrophysiological monitoring, MDU, intraoperative ICG videoangiography, and endoscopy can substantially improve microsurgical outcome.

[The strategy of management for bilateral carotid atherosclerotic stenosis].

OBJECTIVE: To evaluate the indication, time and strategy of surgery for patients with bilateral carotid atherosclerotic stenosis. METHODS: Seventy-four patients with bilateral carotid atherosclecrotic stenosis were admitted to our hospital from February 1987 to December 2007. In 34 patients who presented with unilateral symptoms and underwent ipsilateral carotid endarterectomy (CEA), contralateral CEA or carotid artery stenting (CAS) was performed in 8 because of severe stenosis (> 70%) or unstable plaque. Thirty-eight patients presented with bilateral symptoms. Among them, 15 underwent CEA on both sides, 3 were performed CEA on one side and CAS on the other side, while 20 underwent unilateral CEA only. In 2 asymptomatic patients, CEA was also performed. RESULTS: Ninety-three cases of CEA were performed in 74 patients. Sixty-eight patients were uneventful after operation. Neurological deficits deteriorated in 2 patients. Four patients developed cardiac ischemia, cerebral hemorrhage and hoarseness respectively. Sixty-seven patients were followed-up for 4.9 years. No cerebral ischemia relevant to operated carotid artery developed in 63 patients. CONCLUSIONS: If the indication is obvious, CEA should be performed no matter how contralateral carotid artery is. The strategy of therapy is individual. Whether using shunt depends on intra-operative monitoring.

Surgical management of large and giant intracavernous and paraclinoid aneurysms.

BACKGROUND: Due to their location, large and giant intracavernous and paraclinoid aneurysms remain a challenge for vascular neurosurgeons. We identified characteristics, surgical indications and treatment strategies of large and giant intracavernous and paraclinoid aneurysms in 36 patients. METHODS: The pterional approach was routinely used. The cervical internal carotid artery was exposed for proximal control of parent vessel and retrograde suction decompression. Paraclinoid aneurysms were directly clipped, intracavernous pseudoaneurysm was repaired and the intracavernous aneurysms were trapped with extracranial-intracranial bypass of saphenous vein graft. Intraoperative electroencephalogram (EEG) and somatosensory evoked potential (SSEP) monitoring were used to detect cerebral ischemia during the temporary occlusion of parent arteries. Microvascular Doppler ultrasonography was used to assess blood flow of the parent and branch vessels. Endoscopy was helpful particularly in dealing with internal carotid artery posterior wall aneurysms. Postoperative digital subtraction angiography (DSA) was performed in 33 of the 36 patients. RESULTS: Thirty-two paraclinoid aneurysms were directly clipped, 1 intracavernous pseudoaneurysm was repaired and the other 3 intracavernous aneurysms were trapped with revascularization. Except for two patients who died in the early postoperative stage, 34 patients' follow-up was 6 - 65 months (mean 10 months) and a Glasgow Outcome Scale score of 4 to 5 at discharge. At the 6-month follow-up examination, Rankin Outcome Scale scores were 0 to 2 in 32 patients. EEG and SSEP monitoring changed in six patients. Twelve clips were readjusted when insufficient blood flow in parent and branch vessels was detected. Three posterior wall aneurysms were clipped. CONCLUSIONS: Intracavernous aneurysms not amenable to endovascular treatment should be treated surgically and surgical treatment is the first option for paraclinoid aneurysms. The temporary parent vessel occlusion, retrograde suction decompression, endoaneurysmectomy, parent vessel reconstruction, vascular anastomosis, electrophysiological monitoring, Doppler ultrasonography and endoscopy are essential techniques in the treatment of the large and giant intracavernous and paraclinoid aneurysms.